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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3660_Библиотеки_им_академика_М_И_Перельмана
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336 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Skin and Hemovac
The skin is closed with subcutaneous stitches of 3-0 or 4-0 Vicryl followed by a running subcuticular stitch of
undyed 4-0 Vicryl. The Hemovac drain that lies inside the carotid sheath is brought out, always through the caudal end of the wound and with care taken not to harpoon the external jugular vein in the process. As mentioned,
the Hemovac drain is placed to canister suction only and is removed on the rst post-operative day. I have found
that the use of the Hemovac drain prevents the large ecchymotic neck frequently associated with subcutaneous
dissection of minor wound bleeding. In my patients, the heparin is not reversed intra-operatively and they are
placed back on their aspirin regimens immediately after surgery. This illustration is to show the Hemovac; the
skin closure has not begun yet.
CHAPTER 4A: SURGICAL TECHNIQUE 337
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338 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-99
Skin Closure
We now close carotid incisions with a running subcuticular stitch and dermabond adhesive to anneal the skin
edges, which allows the patient to cleanse the wound and provides an excellent cosmetic result as the sutures
dissolve and the skin attens out. The incision is barely visible after 6 months, despite my preference for a vertical sternomastoid-based incision rather than a horizontal skin crease-type opening.
CHAPTER 4A: SURGICAL TECHNIQUE 339
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340 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Placement of Saphenous Vein
Patch Graft
For the sake of completeness, I included this illustration of a saphenous vein patch graft. I no longer use this
technique, and have converted entirely to the Hemashield graft material.
The technique is simple whether the case is shunted or un-shunted. An elliptic-shaped patch graft is fashioned from high saphenous vein and oriented so that there will be no valves to impede the column of ow. An
anchor bite is then placed in the ICA, and a long suture line is run along the medial aspect of the repair. The
lateral aspect of the repair is closed with a two-armed suture line, just as in a primary carotid repair, facilitating
evacuation of the intra-luminal contents prior to nal closure and likewise facilitating removal of the shunt if a
shunt has been called for by monitoring parameters.
CHAPTER 4A: SURGICAL TECHNIQUE 341
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CHAPTER 4B
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Surgical Technique
Satoshi Kuroda
343
344 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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General Anesthesia and
Skin Incision
We use general anesthesia with oral intubation. We do not use nasal intubation because of the risk of nasal hemorrhage and other problems.
It is quite important to identify the mandible, parotid gland, mastoid process, and sternocleidomastoid
muscle when making a skin incision. In Asian patients, the bifurcation of carotid artery is usually higher than in
Western people. Thus, it is not rare to have to extend the skin incision to the tip of mastoid process. We prefer to
use a skin incision along the anterior margin of the sternocleidomastoid muscle inferiorly and then around the
posterior margin of the parotid gland superiorly to reach the tip of the mastoid process. By doing so, we avoid
damage to the parotid gland and facilitate the identication of the great auricular nerve on the sternocleidomastoid muscle.
CHAPTER 4B: SURGICAL TECHNIQUE 345
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Platysma Incision
The incision is made sharply with a No. 20 scalpel, and the platysma is incised with a monopolar coagulator. It
is important to use 6–7 hooks to provide adequate tension to the wound after the skin incision.
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